Provider Demographics
NPI:1912227059
Name:C. MARSHALL BRADSHAW MD PA
Entity Type:Organization
Organization Name:C. MARSHALL BRADSHAW MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:MARSHALL
Authorized Official - Last Name:BRADSHAW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:806-355-1559
Mailing Address - Street 1:6103 W AMARILLO BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106-1936
Mailing Address - Country:US
Mailing Address - Phone:806-355-1559
Mailing Address - Fax:806-355-2273
Practice Address - Street 1:6103 W AMARILLO BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-1936
Practice Address - Country:US
Practice Address - Phone:806-355-1559
Practice Address - Fax:806-355-2273
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-10
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD2367174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty